NHS STANDARD APPLICATION FORM

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NHS STANDARD APPLICATION FORM
Please fill in the application form below. Do not type/write
using only capital letters and please remember to check it
carefully, as once the form has been submitted it cannot be
changed.
For Office Use Only
Online Reference Number:
APPLICATION FOR EMPLOYMENT WITH
ROYAL NATIONAL ORTHOPAEDIC HOSPITAL
APPLICATION FOR EMPLOYMENT
Details entered in this part of the form will be held by the recruiting employer. Access to this
information will be withheld from the shortlisting panel. Please do not type/write using only
capital letters, as this could lead to your application being automatically rejected. Please use the
appropriate mixture of capital and lowercase letters in standard written text.
Job Reference Number
Job Title
Department
Personal Details
Title
*Surname/Family Name
*First Name
Middle Name
Name in which you are registered
with a professional body (if
applicable)
UK National Insurance No
Address
*Postcode/ Zip code
*Country
Home Telephone
Mobile Telephone
(only if UK registered)
Work Telephone
Preferred telephone number
NHS standard Application form Website 140414 (2)
 Home
 Mobile
Confidential
 Work
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Email Address
*Are you a United Kingdom (UK), European Community (EC) or European Economic Area
(EEA) National?
 Yes
 No
If you have answered ‘no’ above, you must answer these questions:
Please select the category that relates to your current immigration status. This status will be
subject to checking before interview.







Highly Skilled Migrant Programme/Tier 1
Indefinite Leave to remain/enter
Work Permit/Tier 2
Dependant / Spouse visa
Clinical attachment visa
Tier 4 student
Visitor
 Post Graduate Doctors and Dentists
 Tier 5 Temporary Workers
 Tier 5 Youth Mobility/ working holiday visa
 Refugee
 Other, please specify below
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Please supply details of any visa currently held:
Visa No:
Start Date: (DD/MM/YY)
Expiry Date: (DD/MM/YY)
Details of any Restriction:
Does your visa have a condition restricting employment or occupation in the UK?
 Yes
 No
Are you an NHS professional returning to practice?
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 Yes
 No
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APPLICATION FOR EMPLOYMENT
Details entered in this part of the form will be held by the recruiting employer and will be made
available to the short-listing panel.
Job Title
Department
Education & Professional Qualifications
All relevant qualifications. Please also indicate subjects currently being studied. All
qualifications disclosed will be subject to a satisfactory check.
Year
Subject/Qualification
Place of Study
Grade/result
obtained
Training Courses Attended
Training courses that you have attended or details of courses that you are currently
undertaking, together with the date completed or to be completed.
Year
Course Title
Training Provider
Duration
obtained
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Membership of Professional Bodies
Please provide details regarding any relevant professional registrations or memberships. This
information will be subject to a satisfactory check.
* Please indicate your UK Professional Registration status *
 I do not have the relevant UK professional registration status
 I have current UK professional registration
 UK professional registration required and applied for
 UK professional registration required but not yet applied for
 I am a student
 Not required for this post
If professional registration is not required then go to Employment History.
If you have answered ‘I have current UK professional registration relevant for this post’ or ‘I
have current UK professional registration and licence to practise for this post’, then please
enter the relevant details below.
Membership or
Membership/Registration Expiry/Renew
Professional Body
Registration type
Number
al Date
If you are applying for a post that requires professional registration you are required to provide
the following information:
Are you currently the subject of a fitness to practise investigation or
proceedings by a licensing or regulatory body in the UK or in any other
country?
 Yes
 No
If applicable, please provide details of any investigations or proceedings you may be subject
to.
Have you been removed from the register or have conditions been made
on your registration by a fitness to practise committee or the licensing or
regulatory body in the UK or in any other country?
Yes
 No
If applicable, please provide details of any conditions you may have.
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Employment History
Please record below the details of your full employment history beginning with your current or
most recent first. If required, please provide additional information regarding your employment
history within the 'Supporting Information' section.
Start of continuous NHS service (If applicable)
(MM/YYYY)
Months since most recent employment ended (if applicable)
Current/most recent employer
Employer Name
Address
Type of Business
Telephone
Job Title
Start Date (MM/YYYY)
End Date (MM/YYYY)
Grade
Salary
Reporting to (job title)
Period of notice
Reason for leaving (if applicable)
Brief description of your duties and responsibilities
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Previous Employer 1
Employer Name
Address
Type of Business
Telephone
Job Title
Start Date (MM/YYYY)
End Date (MM/YYYY)
Grade
Salary
Reporting to (job title)
Period of notice
Reason for leaving (if applicable)
Brief description of your duties and responsibilities
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Previous Employer 2
Employer Name
Address
Type of Business
Telephone
Job Title
Start Date (MM/YYYY)
End Date (MM/YYYY)
Grade
Salary
Reporting to (job title)
Period of notice
Reason for leaving (if applicable)
Brief description of your duties and responsibilities
Previous Employer 3
Employer Name
Address
Type of Business
Telephone
Job Title
Start Date (MM/YYYY)
End Date (MM/YYYY)
Grade
Salary
Reporting to (job title)
Period of notice
Reason for leaving (if applicable)
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Brief description of your duties and responsibilities
Previous Employer 4
Employer Name
Address
Type of Business
Telephone
Job Title
Start Date (MM/YYYY)
End Date (MM/YYYY)
Grade
Salary
Reporting to (job title)
Period of notice
Reason for leaving (if applicable)
Brief description of your duties and responsibilities
Previous Employer 5
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Employer Name
Address
Type of Business
Telephone
Job Title
Start Date (MM/YYYY)
End Date (MM/YYYY)
Grade
Salary
Reporting to (job title)
Period of notice
Reason for leaving (if applicable)
Brief description of your duties and responsibilities
Previous Employer 6
Employer Name
Address
Type of Business
Telephone
Job Title
Start Date (MM/YYYY)
End Date (MM/YYYY)
Grade
Salary
Reporting to (job title)
Period of notice
Reason for leaving (if applicable)
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Brief description of your duties and responsibilities
Please add additional employers/information on a separate sheet.
Employment Gaps
If you have any gaps within your employment history, please state the reasons for the gaps
below.
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References
Please provide the names and full contact details of the people who have agreed to supply
references. References must include at least two positions, one being from your current or
most recent employer, with separate employers and, as a minimum, cover a period of three
years employment and/or training history, where this is possible.
Referees will be required to comment on your competence, personal qualities and suitability for
the post. This may be your line/department manager, or someone in a position of responsibility
for any work experience or placement undertaken. If you are a student or trainee this should
include a teacher/tutor at your education institution.
If you have not been in employment for a considerable amount of time but have had previous
employment, then you should seek one reference from your last known employer and a
personal reference from a person of standing within your community such as a doctor, solicitor
or MP. Where it is genuinely not possible to obtain references from any of the sources outlined
above, you must provide contact details of two personal acquaintances who would be willing to
give a reference. Personal acquaintances must not be related to you, or have any financial
arrangement with you.
Please note that all reference requests will be followed up and verified by the recruiting
employer.
Referees may be approached prior to interview, unless you indicate otherwise below.
Referee 1
* Type of Reference
 Employer
 Educational
 Personal
Title
*Surname/Family name
* First Name
*Relationship
Employer Name
Referee Job Title
*Address
*Postcode/ Zip Code
Telephone
*Country
Email
*Can the referee be
contacted prior to
interview?
Fax
 Yes
NHS standard Application form Website 140414 (2)
 No
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Referee 2
* Type of Reference
 Employer
 Educational
 Personal
Title
*Surname/Family name
* First Name
*Relationship
Employer name
Referee Job Title
*Address
*Post Code/ Zip Code
Telephone
*Country
Email
*Can the referee be
contacted prior to
interview?
Fax
 Yes
 No
If you have applied to us within the last 3 months,
are you happy for us to use the references from
your earlier application?
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 Yes
 No
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Supporting Information
In this section please give your reasons for applying for this post and additional information
which demonstrates that you have read the published person specification and how you meet
the essential and (where relevant) desirable criteria for this particular position. This can include
relevant skills, knowledge, experience, voluntary activities, training etc.
If relevant to the post for which you are applying, you should include details about research
experience, publications or poster presentations, clinical care (knowledge and skills) and clinical
audit.
* Supporting information (Please continue on additional sheets if necessary).
Additional Personal Information
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Preferred Employment
Type
 Full Time  Part Time
 Flexible Hours
 Job Share Secondment
Declaration
The information in this form is true and complete. I agree that any deliberate omission,
falsification or misrepresentation in the application form will be grounds for rejecting this
application or subsequent dismissal if employed by the organisation. Where applicable, I
consent that the organisation can seek clarification regarding professional registration details.
I agree to the above declaration
Signature
Name
Date
Where did you see this vacancy advertised?
 NHS Website
 Search Engine
 Other Website
 National
Newspaper
 Local Newspaper
 British Medical
Journal
 British Dental Journal
 Health Service
Journal
NHS standard Application form Website 140414 (2)
 Doctor
 Therapy Weekly
 Nursing Times
 GP
 Hospital Doctor
Confidential
 Nursing Standard
 Other Professional
Journal
 Jobcentre Plus
 Radio
 Other
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MONITORING INFORMATION
NHS organisations recognise the benefits of having a diverse workforce and therefore welcome
applications from all sections of the community. In addition to this, under the provisions of the
Equality Act 2010, all NHS organisations are required to demonstrate that their recruitment
processes are fair and that they are not discriminating against or disadvantaging anyone
because of their age, disability, gender reassignment status, marriage or civil partnership status,
pregnancy or maternity, race, religion or belief, sex or sexual orientation. Therefore a series of
questions need to be raised in order to ascertain who is applying for each position and to
ensure that no one is being unfairly discriminated against or disadvantaged.
This section of the application form will be detached from your application and will not be used
as part of the selection process nor will it be seen by anybody who is interviewing you. The
information collected is only used for monitoring purposes in an anonymised format to assist the
organisation in analysing the profile and make up of individuals who apply, are shortlisted for
and appointed to each vacancy. In this way, they can check that they are complying with the
Equality Act 2010.
Equality Act 2010
The Equality Act 2010 protects people against discrimination on the grounds of their age and
sex.
*
*
Please state your date of birth
Please indicate your gender
 Male
 Female
 I do not wish to disclose this
Equality Act 2010
The Equality Act 2010 protects people who are married or in a civil partnership.
* Please indicate the option which best describes your marital status
 Married
 Divorced
 Single
 Widowed
 Civil partnership
 I do not wish to disclose this
 Legally separated
Equality Act 2010
The Equality Act 2010 protects bisexual, gay, heterosexual and lesbian people from
discrimination on the grounds of their sexual orientation.
* Please indicate the option which best describes your sexual orientation
 Lesbian
 Gay
 Bisexual
NHS standard Application form Website 140414 (2)
 Heterosexual
 I do not wish to disclose this
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Equality Act 2010
The Equality Act 2010 protects people against discrimination on the grounds of their race which
includes colour, nationality, ethnic or national origin.
*
Please indicate your ethnic origin
Asian or Asian British
 Bangladeshi
 Indian
 Pakistani
 Any other Asian
background
Black or Black British
 African
 Caribbean
 Any other Black
background
Mixed
 White & Asian
 White & Black African
 White & Black Caribbean
 Any other mixed
background
White
 British
 Irish
 Any other White
background
Other Ethnic Group
 Chinese
 Any other ethnic
group
 I do not wish to
disclose this
Equality Act 2010
The Equality Act 2010 protects people against discrimination on the grounds of their religion or
belief, including a lack of any belief.
* Please indicate your religion or belief
 Atheism
 Islam
 Other
 Buddhism
 Jainism
 I do not wish to disclose this
 Christianity
 Judaism
 Hinduism
 Sikhism
Equality Act 2010
The Equality Act 2010 protects disabled people - including those with long term health
conditions, learning disabilities and so called "hidden" disabilities such as dyslexia. If you tell us
that you have a disability we can make reasonable adjustments to ensure that any selection
processes - including the interview - are fair and equitable.
* Do you consider yourself to
 Yes
 No
have a disability?
 I do not wish to disclose this information
Please state the type of impairment which applies to you. People may experience more than
one type of impairment, in which case you may indicate more than one. If none of the
categories apply, please mark ‘other’.
 Physical impairment
 Learning Disability/Difficulty
 Sensory impairment
 Long-standing illness
 Mental health condition
 Other
If you have a disability, do you wish to be considered under the guaranteed interview scheme
if you meet the minimum criteria as specified in the person specification?
 Yes
 No
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Rehabilitation of Offenders Act 1974
The Rehabilitation of Offenders Act 1974 (as amended) helps rehabilitated ex-offenders back
into work by allowing them not to declare criminal convictions after the rehabilitation period set
by the Court has elapsed and the convictions become 'spent'. During the rehabilitation period,
convictions are referred to as 'unspent' convictions and must be declared to employers.
The organisation aims to promote equality of opportunity and is committed to treating all
applicants for positions fairly and on merit regardless of ethnicity, disability, age, gender or
gender re-assignment, religion or belief, sexual orientation, pregnancy or maternity and
marriage or civil partnership. The organisation undertakes not to discriminate unfairly against
applicants on the basis of a criminal conviction or other information declared.
You are required to declare all current ‘unspent’ criminal convictions or cautions (including
reprimands and final warnings). You are not required to disclose convictions or cautions which
have become ‘spent’.
As part of assessing your application, organisations will only take into account relevant criminal
record and other information declared which is relevant to the position being applied for.
Answering ‘yes’ to the question below will not necessarily bar you from appointment. This will
depend on the relevance of the information you provide in respect of the nature of the position
for which you are applying and the particular circumstances.
* Are you currently bound over or do you have any current ‘unspent’ convictions or cautions
(including reprimands or warnings) that have been issued by a Court or Court-Martial in the
United Kingdom or in any other country?
 Yes
 No
If Yes, please include details of the order binding you over and/or the nature of the offence,
the penalty, sentence or order of the Court, and the date and place of the Court hearing. You
do not need to tell us about parking offences.
Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (Amendment)
(England and Wales) Order 2013
The position you are applying for has been identified as being an 'eligible position' under the
Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 [the Exceptions Order] and, in
certain circumstances, the Police Act 1997. As such, it meets the eligibility criteria for a
standard or an enhanced disclosure to be requested through the Disclosure and Barring Service
(DBS).
Both standard and enhanced DBS disclosure certificates contain information about any
convictions, cautions (including reprimands and final warnings) which are not 'protected' as
defined by the Rehabilitation of Offenders Act 1974 (Exceptions Order) 1975 (as amended).
Enhanced disclosures may also include other relevant police information where this is deemed
relevant to the position you are applying for.
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Please be aware that the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975
(Amendment) (England and Wales) Order 2013 (S.I. 2013/1198) made amendment to the
Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 to provide that certain spent
convictions and cautions will become protected when specific conditions are met. Protected
convictions and cautions will not be disclosed in a DBS check, and employers cannot ask for
information about protected convictions or cautions, or take these into account when
considering you for appointment.
Before you complete the question(s) below please read guidance and criteria for the filtering of
these convictions and cautions which can be found on the Disclosure and Barring Service
website at: www.gov.uk/government/organisations/disclosure-and-barring-service
Where the position has, in addition, been identified as a regulated activity under the
Safeguarding Vulnerable Groups Act (2006) (as amended by the Protection of Freedom's Act
2012) an enhanced DBS disclosure will include information which is held on the Children's
and/or Adults barred list(s), as applicable to the position.
Please note that you do not need to tell us about convictions, cautions, warnings or reprimands
which are deemed 'protected' under the Rehabilitation of Offenders Act 1974 (Exceptions) Order
1975 as amended by the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975
(Amendment) (England and Wales) Order 2013 - see notes above. You also are not required to
tell us about parking offences.
* Are you currently bound over, or do you have any convictions or cautions (including
warnings and reprimands) which are not deemed 'protected' under the amendment to the
Exceptions Order 1975, issued by a Court or Court-Martial in the United Kingdom or in any
other country?
 Yes
 No
If YES, please include details of the order binding you over and/or the nature of the offence,
the penalty, sentence or order of the Court, and the date and place of the Court hearing.
* Are you currently bound by any barring decision made by the Disclosure Barring Service
(DBS) from working with children?
 Yes
 No
* Are you currently bound by any barring decision made by the Disclosure Barring Service
(DBS) from working with vulnerable adults?
 Yes
 No
Relationships
If you are related to a director, or have a relationship with a director or employee of an
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appointing organisation, please state the relationship:
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